THE LAST OF MY “FOOD BLOGS” FOR A WHILE.

After blogs about the evils of excess added sugar, added trans fats, the obfuscation of ingredient lists, and manipulative marketing by food manufacturers I find it easy and appropriate to finish up this series with pictures that capture more than I can write.

Some churches have come up with the ultimate answer to WWJD? Gluten-free communion wafers!!

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Wouldn’t it be great if parents were as paranoid about gun deaths – 500 children per year – as we are about peanut allergy deaths – 150 children and adults per year.

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As a pediatrician with 45 years of experience and a grandfather, I think that the moment depicted here is much more important in the long run for the child than reading the % of trans fat or sugar content in the ingredients list.

Washington – April 10, 2014
“A welcome relief from rising health care cost for U.S. consumers is being less warmly received by the Federal Reserve.”

Mr. Abbott, a Washington economist, is heard explaining it to Dr. Costello, a physician.

A: The cost of health care services rose just 0.8% this year.
C: That’s good news. We all have been working hard to reduce costs,what with meaningful use, and evidence-based medicine, and transparent patient portals. It’s hard work.
A: Its not good news.
C: What?
A: Health care sevice prices are down from its 10 year average of 2.6% increase.
C: That’s really good.
A: No,its not.
C: Why?
A: It’s a sign of persistent deflation.
C: Aren’t we afraid of inflation?
A: Not now.
C: What?
A: Their current goal is 2% inflation.
C: Whose?
A: The Federal Reserve.
C: Who?
A: They measure the economy.
C: How?
A: Using the Personal Consumption Expenditures or PCE.
C: What?
A: LIke the Consumer Price Index, the PCE measures what people spend on things.
C: Why?
A: People spending more money on things means the economy is growing stronger.
C: Who says?
A: Mr. Bush. Remember, he asked us all to go shopping to get out of the recession.
C: Where?
A: In America, of course.
C: What do health care services have to do with the mall?
A: Health care services make up 25% of the prices measured by the PCE.
C: So what.
A: Physician fees went up only 0.2%, down from 1.6% in 2012.
C: THAT’S not good for me!
A: No, its not.
C: What!?
A: Nursing home prices went up only 0.3% rather than the 1.8% rise of two years ago.
C: I know, I know. That sounds good but its not?
A: Right!
C: Why?
A: If health care prices don’t go up, the PCE doesn’t go up, and our economy looks stagnant.
C: Oh, boy! I think I got it. If all the efforts to reduce health care costs succeed, the PCE will not rise, inflation will be less than 2% a year, deflation will persist, and the Federal Reserve will label the economy as stagnant.
A: Now you’ve got it!
C: What about the impact of the Affordable Care Act?
A: Economists agree that the impact of Obamacare is not yet clear.
C: Oh boy!
A: Any questions?
C: Just one.
A: What?
C: Who’s on first?

PUTIИCAЯE UNVEILED

Vladimir Putin, President of the Russian Federation, today unveiled his country’s plan for universal medical care, the Accessible Care Act (ACA) or Putincare. The act was passed by a unanimous vote in both the Upper and Lower Houses, “an easy task of collective wisdom once we eliminated the ‘individual mandate’ clause.” Mr. Putin remarked that he had hoped to make the announcement while on the crest of success of the Sochi Olympics, but that the unexpected expression of states’ rights in the Ukraine distracted him. “I understand”, Mr. Putin went on to say, “that Mr. Obama sometimes has his own problems with state’s rights, but our Georgia is not like his Georgia”.

Putincare will establish medical care Exchanges in all states belonging to the Russian Federation. Every citizen (Yes, EVERY citizen. After all, the number of immigrants into Russia is not an issue.) will be able to bring in pigs, or chickens, or even potatoes and exchange them for medical care. Each Exchange will set its own eligibility criteria and rates. For example, in Georgia one pig could be exchanged for a throat culture and ten days of penicillin while in Moscow the same would cost one pig PLUS the names of two suspicious neighbors. The urban-based social networks, like “2Facebook”, will encourage this.

Full implementation of Putincare will depend on increasing the number of doctors and nurses in Russia since many towns have none. Despite the concerns expressed by the BAR Association (Babushka Assistants of Russia) that new doctors and nurses will compete unfairly with their services, Putincare calls for the immediate recruiting of as many Indian and Pakistani providers as possible. “It seems to have worked for Britain and America.” Mr. Putin expressed great confidence in their ability to avoid some of the early problems experienced by Obamacare. “Our computer expert, Mr. Snowden, assures us that we will have no problems. Of course, if he is wrong, he will return to America sooner rather than later.”

Putincare, like Obamacare, will not cost any additional money. The medical care provided through the Exchanges will get sick people better and reduce the work days lost due to death. The plan will increase revenue as a result of more pigs, chickens, and even potatoes… not to mention the increased number of State enemies identified in Moscow alone. As proof of the need for this program State spokesmen confirmed reports that one of the Exchanges had collapsed under the weight of 200 pigs. “We were expecting about 25 an hour the first day and so had a floor that could support 100 an hour, but the sudden traffic just overwhelmed us, and we crashed.”

Implementation of the requirement for small business to participate in the Exchanges has been postponed because of unfamiliarity with the term “small business”, some concerns about “creeping capitalism” which would enrich the Exchanges, and the cessation of operations in Russia by Visa and Master Charge brought on by U.S. sanctions. Most of Putin’s close associates were unavailable for comment, being occupied in trying to recover their own frozen assets.

Mrs. Putin, who rarely makes public appearances, will be launching a Russia-wide children’s education effort to support this plan; SISCAK, “Stay In School, the Chinese Are Coming” (rough translation).

Foreign critics of Putincare dismissed this announcement as an obvious attempt to deflect international attention away from the Ukraine. If you read the plan carefully, and we’re not certain anyone has, you will see that there is no Exchange designated for the Crimea. “Federal Russia will provide.”

Donald Berwick, MD, failed-appointee for Chief of Obamacare in America, commented, “Russia needs to improve its cost/quality ratios a great deal. Putincare is a step in the right direction, but I am not certain that even Mother Russia is ready for a Health Czar.”

Several courageous Soviet scientists introduced a sense of urgency to the discussion, “Because of the current state of the world we should not delay. The Siberian permafrost is already getting squishy, … and the Chinese are coming.”

Putin officially ended the press conference with, “We are confident that all the States and Provinces in the Russian Federation will embrace and implement this plan, …and also visit Sochi to help us pay for it. If they do not, the army will march.” Putin’s exit words, whispered aside, were unintentionally recorded, rebroadcast on both The Daily Show and The Colbert Report, and immediately went viral; “Eat your heart out Barrack!

In a solemn Easter Mass Pope Francis dramatically offered the help of the Roman Catholic Church in funding universal health care in the U.S. He noted that because the U.S. is the only civilized Western country without universal health care and is currently having financial problems, it is the Christian thing to do. “Since we all recognize that we are in a global economy and a global health care community, where neither disease nor money is restricted by national boundaries, it makes good sense to protect the rest of the world from the health problems of the beleaguered U.S. ” He felt that it was most fitting and proper to announce this during an Easter Mass with its tradition of hope and renewal. The plan was immediately dubbed, “Francincare” (pronounced as “Frankincare” with the Italian hard “c”).

In an immediately following press conference papal staffers presented details of the plan. Premiums will be collected in envelopes at weekly services and delivered to Medicare headquarters the next week. The premiums collected will be used to pay for all services except contraception and abortion. Those seeking that coverage may attend an additional weekly session at a synagogue, Episcopal, or Presbyterian church once a month. Each parish church will be designated as an Accountable Care Organization (ACO). Participation will not be denied because of pre-existing conditions or previous religious affiliations.

In response to questions from the press, papal staffers did concede that this plan might help bring U.S. Catholics back to church. Dispensing Pneumovax and flu shots after Christmas Mass was one example they gave. HIV screening could be added to pre-Cana programs, but local parishes could opt out of this benefit if they requested a waiver. Plans to convert St. Vincent De Paul consignment shops into dispensaries of low-cost generic drugs are also under consideration.

Papal staffers also emphasized that the system would not waste a lot of money on developing no-return electronic data capability or a questionably effective quality improvement bureaucracy. “We don’t want another large bureaucracy competing with the Curia. All the money collected will be spent on direct patient care… after the usual percentage to the Papal Office is taken out, of course.”

Dr. Jeremy Lazarus, AMA President, referring to the church’s foray into the intricacies of Accountable Care Organizations welcomed the move saying, “It is about time the Catholic church was accountable for something.”

Prelates in France felt that it just might work in the U.S. but it had no relevance for France “where people stopped going to church a long time ago.”

Christina Kirchner, President of Argentina, stated that “Pope Francis and I have had our conflicts in the past over church vs. state matters, and I am pleased that he is first trying this out in North America.”

Mitt Romney, contacted on the floor of a Tea Party conference in Arizona, immediately referred to the offer as “a naked grab for power by a foreign potentate… Frankenstein could be dangerous, I think we should just stay against Obamacare.”

Sean O’Malley, Bishop of Boston, tweeted “gives new meaning to the word frankincense. can’t wait to use it in my Christmas homily. #thenewchurch.”

Obama was reported to have been pleased by the idea, but mused, “I wonder what he thinks of gun control? The Roman Catholic church may be the only organization big enough to take on the NRA.”

The plan was developed in secret over several months and received the final vote of approval during the recent conclave. Earlier drafts of the plan were used to blacken the smoke from the Sistine Chapel prior to Francis’s election.

Papal staffers assured all that the financial reserves of the world-wide church was adequate to sustain the program though its implementation might be slowed by the scarcity of both primary care physicians and priests in the U.S. Efforts to train nuns as both physician and priest delegates will be stepped up. They did note that the plan would not cover any mental health services with the explanation that “We are already conducting weekly, even daily, group therapy sessions. If you add in the out reach efforts of our after-school training classes (used to be called CCD), organized family retreats, and sponsored pilgrimages/cruises to foreign lands, we feel no further mental health coverage will be needed.”

At the end of the press conference Pope Francis returned briefly, bestowed the usual Papal Blessing on the gathering (see Hubslist March 15), and closed with a benediction in Italian, Spanish, and English: “Felice Aprile Ingannare Giorno”,
“Felize Abril Enganar Dia”, and “Happy April Fools Day”

Now that Francis I has succeeded Benedict XVI we should expect some early spring sprouting of stories about Benedict’s medical issues. We already know he had a cardiac pacemaker implanted before he was elected Pope, and that it was “recharged” or “replaced” in a “secret surgical procedure” three months before he retired. He had arthritis (so much for the positive energy of red shoes), a stroke in 1991, and maybe another in 2009 when he fell and hit his head (Oh, NO, one of those currently dreaded “concussions” maybe). Francis I has his own past medical issues, of course. One of his lungs was removed due to a lung infection in his youth. We will, I’m sure, hear a lot more about both of their medical histories.

A more compelling medical speculation surrounded the death of Pope John Paul I in 1978. His death just 33 days after his election spawned several conspiratorial scenarios including links to Chicago (“where Al Capone used to rule”) and the Sicilian mafioso (linked mostly by shared bankers). The non-smoker Pope took medicine only for low blood pressure. He was found sitting up in bed with reading material in his lap the morning after sharing a simple meal with others who drank the wine. He drank only water. He was discovered in bed by a nun which, of course, added to the intrigue. Actually she had delivered his morning cup of coffee every day for forty years. His personal physician examined him in his bed, declared him dead of a ‘heart attack”, and a hurried, “poorly supervised” autopsy was performed. John Paul I was not the shortest-lived Pope. Urban VII (1590) died only 13 days after election, but everyone seemed to agree that malaria killed him.

The medical question I have not been able to answer despite my extensive, exhaustive research (at least an hour on Google) is: Which Pope had the ulnar nerve palsy?
The classic hand gesture of the “Papal Blessing” or “Papal Benediction”, despite erudite analysis by reverent writers on the religious symbolism of his hand and fingers, is, in fact, the result of a nerve palsy of the hand. Even the Vatican tourist guides know this.

There is disagreement over which nerve palsy the originating Pope had. You can find reasoned arguments that it was a median nerve palsy, not an ulnar nerve palsy. Either one results in the curved 3rd and 4th fingers with straight 1st and 2nd ones. The median nerve palsy would result in the gesture if the Pope were trying to make a fist. The ulnar palsy would create the gesture as he tried to wave keeping all fingers straight. The early centuries of the papacy were filled with intrigue, plots, poisonings, warfare, and murder, but somehow I can’t picture the Pope blessing the people with a raised, clenched fist. I vote for him attempting a royal wave, and so align with the ulnar palsy school.

Pope Clement I (92-99 AD) was the third or fourth Bishop of Rome, consecrated by St. Peter himself, and one of his portraits shows him with the classic papal hand gesture.But his portrait was painted at a much later date, so the painter was probably just giving Clement I the “sign of the Pope”. It doesn’t mean that Clement originated it. For some reason in the back of my brain, the name of Urban keeps peeking out, but there were VIII of them so I couldn’t narrow it down. A more learned source attributes the original gesture to Pius V (1566-1572). Others have noted that the gesture historically has not been restricted only to Popes, and has been depicted in photos and portraits of lots of other clergy.

Bishop Fulton Sheen of New York and TV

One of the oddest elements of a papal election is the use in the conclave of the Sedia Stercoraria (pierced chair) as described by a learned source, a “creative club of independent Rome tour guides”.

“In 855, some scholars believe a woman named Joan dared to falsify her gender and was nominated as Pope John VIII. As the story goes, no one was aware of her “double identity” until her death when one of the doctors examined her body and discovered that not only she was a woman but a pregnant woman! Scandal was in the air, so to prevent any kind of misleadings the cardinals came up with a very simple method to make sure that pope is a man. After the election the new pontiff needed to proof that he had…we’ll say, the proper equipment to be a pope. The newly elected Pope has to sit on the chair, while one of the cardinals would examine the situation by placing his head under the chair. As the story goes, if everything was ok the cardinal would say “He has two balls, and they are well hung” bringing a cheerful smile on other cardinals’ faces.”

I doubt that they still use that chair, what with inexpensive rapid DNA testing available.

The Italian bishops were surprised that the Bishop of Milan, Angelo Scola, was not elected, and much to their embarrassment they prematurely released a report that he had been. I, too, was very disappointed that Angelo Scola did not get elected because we all could have called him Pope Scola. … don’t get it? Re-read that last sentence out loud.

This subject springs to my mind this month
because my friend got a free kitten for Christmas last year.
Her daughter had rescued him from a dumpster.
His name is Charlie.
More on Charlie later.

According to industry statistics $13 Billion (yes, that is a “B”) was spent in 2010 on veterinarian care for pets in 73 million households; a 40% increase over 2006. In 2006 there were about 86 million cats in the U.S. If they could vote, and did so as a bloc, they would bury the 78 million dogs. With the number of pets and costs rising like that, I wondered what the pet health insurance market was like. Does the pet health insurance marketplace have lessons, or even “best practices”, for us in our struggle with health insurance costs and coverage for humans? Is it time for an Affordable Care Act for pets? I decided to take a look.

As I surfed through pet health insurance plans I was struck by the similarities to our (human) health insurance plans of the 70’s and 80’s. The subscriber pays the vet and gets reimbursed 90% of “usual and customary” fees. The companies promise “quick-turn around” of claims, of course. The vet has no forms to fill out or sign. The subscriber does it all. These familiar phrases sound like “the good old days” to physicians who now have two or more full-time office people filling out all sorts of insurance billing forms and/or an IT consultant to do it electronically.

You can go to any licensed vet. There is no concern about “eligible providers” or being “out of network”, but policies do differ from state to state. Reimbursement is not dependent on diagnosis (no need for bulky code books or sophisticated computer programs). None of the policies cover pre-existing conditions or preventative care services (routine visits to the vet). Those are optional coverages available for additional premium.

It all sounds pretty simple and straight forward until you start reading more closely. An asterisk here and a double asterisk there sends you to fine-print footnotes defining “eligibility criteria”, “waiting periods”, “continuing care”, “pre-existing conditions”, and “congenital conditions”. That’s not only identical to our “good old days”, but it also holds true today.

A neighbor just spent $400 on the annual visit and necessary vaccines for his three Labradors. When I asked him if he had health insurance for them, he replied, “No way was I going to spend all that time figuring out what they covered, and when, and for how much. It was too complicated. I struggle enough trying to understand the policies I buy for my employees.”

Pet health insurance was started in Sweden in 1924 and was adopted in the U.K. around 1947. The first pet insurance policy in the U.S. was written in 1982 for the protection of our TV hero Lassie. (Do Socialist countries always lead the way in developing health insurance plans?) NAPHIA, North American Pet Health Insurance Association, was founded in 2007. In Canada there are 10 cat health insurance plans while in the U.S. you have the choice of 36 plans for cats. (Capitalism is so-o-o predictable sometimes)

Back to Charlie….Remember Charlie?….This is a blog about Charlie.
He is an extremely cute, solid black kitten that made my friend’s last year’s Christmas stocking begin to wiggle. When his head popped out with those big, wide open green eyes, the mystery of the stocking was over, and the love affair began. Health insurance for him was available after a mandatory 30-day waiting period (the insurance company wanted to be sure he survived that long I guess). The waiting period for coverage of “congenital conditions” is 180 days, presumably for the same reason. It would cost from $4.08 per month to $67.14 per month depending on coverage options, BUT excluded preventative care and routine visits to the vet. After reading Consumer Reports my friend decided not to buy any.

The first visit to the vet cost $103.75. That included $26.00 for a FVRCP shot against Feline Viral Rhinotracheitis, aka “a bad cold”, and $21.75 for a fecal specimen exam. The second visit a month later was $161, and the third month it was $277. That one was higher because of the anesthesia charge for the neutering ($36.00) and a Catalyst Chem 10 test ($62.00). The lab business for pet tests seems as lucrative as for our tests. The neutering operation itself seemed like a bargain at $50.50. It was only slightly higher than the placement of the ID microchip under his skin. (ER docs and police eat your hearts out! The technology is here.)

Rather than continue to bore you with the details, suffice it to say, my friend’s “free” kitten cost over $500 for vet visits in the first year alone. I am not even going to try to total up all the other costs because someone else already has. According to a 2010-2011 survey the average annual maintenance cost of a cat in the U.S. is $1217.

“I once bought my kids a set of batteries for Christmas with a note on it saying, toys not included.” ~Bernard Manning

1. A Gift Certificate for a CT ScanThis is what inspired my slightly twisted view of Christmas giving. Several Christmas’s ago a new private, for-profit imaging center in our town advertised gift certificates for a CT scan to “give to a friend or loved one”. This marketing ploy implied that it was the kind of gift that showed that “you really cared”. Many local physicians considered it as a good gift, not for your friend, but for your enemy.

Besides the considerable exposure to radiation, at least 30% of CT scans performed have an unexpected “finding”; a shadow or bright spot where none is supposed to exist, an organ or other structure that is bigger or smaller than expected, etc. If the radiologist reading the CT scan is particularly compulsive, aggressive, or extraordinarily risk-averse, that “finding” may be called an “abnormality”. Abnormalities need further work-up that usually involves more radiation, use of intravenous and/or oral contrast medium, more aggressive procedures like inserting scopes into various body orifices, and even needle or open biopsy of one of your favorite organs.

Physicians often call these findings, “ditzels“. Since about one out of three people getting a CT scan will have one or two ditzels that prompt a new cascade of diagnostic testing, this is a perfect gift for an enemy. CT scans are a superb diagnostic tool for people who are sick, but they are so sensitive that they are not so great as a screening tool. If you should ever be told that you have a “finding” on your CT scan, just ask the doctor if it is really significant or is just a “ditzel.”

2. A screening mammogram The current controversy surrounding the mammogram as a screening test for breast cancer makes this a perfect gift for that passive-aggressive Ex whose impenetrable ambivalence was so vexing. Data about the number of “false positive” or equivocal results in mammograms that generate lots of repeat imaging, more expensive imaging technology, consultation referrals, biopsies, and even “unnecessary” surgery and chemotherapy has reordered the risk/benefit ratio of screening mammograms. Different scientific groups have different guidelines for when (women can be too young or too old) and how often (annual, every three years, once?) women should get one. Several studies indicate that mammogram screening has not improved the survival rate of women with breast cancer at all. A side effect of the drive for early diagnosis is that “if you look really hard , you find forms that are ultimately never going to bother the patient” (1)

3. A Prostate Specific Antigen (PSA) blood testThis is a very suitable response from the woman who gets a mammogram gift from her despised Ex. This very popular test has lost its initial considerably positive blush as more and more data appeared that the PSA has had no real impact on reducing the death rate from prostate cancer (spoiler alert: deaths from prostate cancer itself are so few that most studies try to focus on “quality of life” measures.). The PSA’s simple number can prompt a lot of unnecessary specialist consultations, biopsies, and even aggressive surgery.

Besides raising your Ex’s anxiety while awaiting the results, an “abnormally high result” suggests the presence of cancer. This usually causes your Ex to enjoy a series of awkward digital (by finger, that is) rectal exams and even multiple long needle biopsies. The biopsy needles are inserted just below his scrotum as he lies flat on his back with his feet up in stirrups (“sweet justice” you might say if you have happened to bear any of his children.)

Of interest to you as his Ex, an abnormally high PSA may also be caused by an ejaculation within the previous two weeks. About 7% of men who do get biopsied (an office procedure) have to be hospitalized within 30 days for post-biopsy complications. “The overall balance of benefits and harms results in moderate certainty that PSA-based screening…has no net benefit“.

4. A motorcycle for the one you really hate.
About 4,500 people died in motorcycle crashes last year. That is 1 in 7 of people killed on the nation’s roads annually. This is double the death rate in 1997 while car fatalities decreased by 5% last year. If you are in a motorcycle crash you are 30 times more likely to die than people in car crashes. Of course, if you gift him a helmet he could drop his chances of death by a third. In case he or she doesn’t get the point, include a certificate granting him or her amnesty for NOT wearing a helmet in the 19 states that require it by law. (2)

5. A year’s supply of vitamins and other supplementsThis is the perfect gift for that annoying vegetarian marathoner friend who won’t stop badgering you to eat healthier and get more exercise. The initial response of gratitude at your surprising thoughtfulness and respect for his life style may fade as he reads the fine print or comes across select issues of Consumers Report. Multiple studies in peer-reviewed medical journals have found no decrease in cardiovascular disease, cancer incidence, or death for any reason among multivitamin users. In a study of over 35,000 men the incidence of prostate cancer was elevated by 17% in those who took Vitamin E supplements. Supplemental calcium (a 1 gram pill per day) with or without any supplemental vitamin D increased the risk of both heart attack and stroke.

Stocking stuffers for those who don’t want to make a big committment, and two holiday tips:
1. gift certificate for 6 sessions in a tanning booth. (for every 4 visits the risk of skin cancer increased by 15%) (Cancer Research Oct. 2011)
2. gift certificate for an MRI for back pain. (2/3 of asymptomatic people showed “serious disk problems” on their MRI) (NEJM 1994)
3. a bumper sticker that says, “Give your kid a motorcycle for his LAST birthday”.
4. a supply of statins (anticholesterol medication) to anyone over 70 yo. (a high cholesterol may decrease heart attacks in the elderly)
5. a chest x-ray to screen for lung cancer (no benefit) (JAMA Oct.26,2011)
6.. forget the cell phone – it won’t cause brain cancer.
7. But remember, if you leave milk and cookies out for Santa Claus make sure they are lactose-free and gluten-free…and FORGET about peanuts. You don’t want a swollen, wheezing Santa Claus with diarrhea stuck in your chimney Christmas morning.